Marvin Michael R, Ferguson Nicole, Cannon Robert M, Jones Christopher M, Brock Guy N
Division of Transplantation, Hiram C. Polk Jr., M.D. Department of Surgery, University of Louisville, Louisville, KY.
Liver Transpl. 2015 May;21(5):612-22. doi: 10.1002/lt.24098. Epub 2015 Apr 15.
Multiple studies have demonstrated an advantage for hepatocellular carcinoma (HCC) patients under the current liver allocation system, such that the United Network for Organ Sharing (UNOS) recently voted in support of a proposal to delay granting Model for End-Stage Liver Disease (MELD) exception points to all HCC patients for 6 months, independently of a candidate's native MELD score or alpha-fetoprotein (AFP) level. We obtained UNOS data on adult patients who were added to the wait list between January 22, 2005 and September 30, 2009, and we explored the relationship between HCC, MELD, AFP, and other factors that contribute to not only dropout on the wait list but posttransplant survival as well. The aim was to establish an equivalent Model for End-Stage Liver Disease (MELDEQ ) score for HCC patients that would reduce the disparity in access to transplantation between HCC and non-HCC patients. We determined risk groups for HCC patients with dropout hazards equivalent to those of non-HCC patients, and we evaluated projections for HCC wait-list dropout/transplantation probabilities on the basis of the MELDEQ prioritization scheme. Projections indicate that lower risk HCC patients (MELDEQ ≤ 18) would have dropout probabilities similar to those of non-HCC patients in the same MELD score range, whereas dropout probabilities for higher risk HCC patients would actually be improved. The posttransplant survival of all HCC risk groups is lower than that of their non-HCC counterparts, with 1-year survival of 0.77 (95% CI, 0.70-0.85) for MELDEQ scores ≥ 31. These results suggest that HCC patients with a combination of a low biochemical MELD score and a low AFP level (MELDEQ ≤ 15) would receive a marked advantage in comparison with patients with chemical MELD scores in a similar range and that a delay of 6 months for listing may be appropriate. In contrast, patients with MELDEQ scores > 15 would likely be adversely affected by a universal 6-month delay in listing.
多项研究表明，在当前的肝脏分配系统下，肝细胞癌（HCC）患者具有优势，因此器官共享联合网络（UNOS）最近投票支持一项提案，即推迟给予所有HCC患者终末期肝病模型（MELD）例外加分6个月，而不考虑候选者的原始MELD评分或甲胎蛋白（AFP）水平。我们获取了UNOS关于2005年1月22日至2009年9月30日期间加入等待名单的成年患者的数据，并探讨了HCC、MELD、AFP以及其他不仅导致等待名单上退出而且影响移植后生存的因素之间的关系。目的是为HCC患者建立一个等效的终末期肝病模型（MELDEQ）评分，以减少HCC患者与非HCC患者在移植机会上的差距。我们确定了HCC患者中退出风险与非HCC患者相当的风险组，并根据MELDEQ优先排序方案评估了HCC等待名单退出/移植概率的预测。预测表明，低风险HCC患者（MELDEQ≤18）的退出概率与相同MELD评分范围内的非HCC患者相似，而高风险HCC患者的退出概率实际上会有所改善。所有HCC风险组的移植后生存率均低于非HCC对应组，MELDEQ评分≥31的患者1年生存率为0.77（95%CI，0.70 - 0.85）。这些结果表明，与化学MELD评分在相似范围内的患者相比，生化MELD评分低且AFP水平低（MELDEQ≤15）的HCC患者将获得显著优势，推迟6个月列入名单可能是合适的。相比之下，MELDEQ评分>15的患者可能会因普遍推迟6个月列入名单而受到不利影响。
